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Ombudsman Program Effectiveness and Quality Assurance

Ombudsman Program Effectiveness


A Self-Evaluation and Continuous Quality Improvement Tool for State and Local Ombudsman Programs
Developed by Robyn Grant, MSW, for both state and local ombudsmen programs. The tool provides State and Ombudsmen program representatives with an instrument for conducting a self-assessment of their program to identify the program’s strengths and areas in need of improvement. Information and recommendations were used to determine 13 components deemed fundamental to having a strong, effective ombudsman program. The elements within each component (indicators) used to assess the program are considered to be exemplary practices that programs should strive to achieve.

Completing the Self-Evaluation Tool can help Ombudsmen:

  • Develop an action plan tailored to address the particular needs of his/her program
  • Set goals/priorities for his/her program
  • Establish benchmarks for his/her program
  • Meet the requirements of the Older Americans Act
  • Identify ombudsman program best practices
  • Identify training needs
  • Gain a greater understanding of the ombudsman program if the Ombudsman is new
  • Prepare for a program audit or evaluation

State Ombudsman

Ombudsman Program Representatives

Mini-Tool: Self-Evaluation and Continuous Quality Improvement Tool
The Mini-Tool is a condensed version of the original instrument that allows for a quick, initial assessment of a statewide program to identify areas for improvement and areas of strength. Once those program areas are identified, the user can move on to the comprehensive evaluation tool for an in-depth assessment of each component.

WEBINAR - Program Effectiveness: Self-Evaluation Tools for Long-Term Care Ombudsman Programs
This webinar provides an overview of the self-evaluation tool, demonstrates how to use the tool, features presentations from Ombudsmen (SLTCO and LLTCO) that have used the tool and introduces the mini-tool. Listen to the recording here and view the PowerPoint slides (PDF versionPPT version).

Quality Assurance


Ohio Designation and Service Review (DSR)
The Ohio Office of the State Long-Term Care Ombudsman’s Program conducts a quality assurance and program monitoring review annually. At the end of the review, the State Office and Regional Program produce a Summary & Action Plan for Quality (APQ) that require three updates to the state office demonstrating implementation of the plan. If those updates are sufficiently satisfactory, designation may be extended an additional year. The objective of this review is to identify successful practices that can be shared, incorporated into training, included in policies, etc., as well as identify areas for improvement and how best to address them (i.e. additional training, guidance, oversight). The tools utilized in this monitoring process are listed below:

  • DSR Announcement – an email announcement is sent to every Regional Program each year in December that contains the date of the program’s monitoring visit, the period of time we will be reviewing, and DSR guidelines. The following documents are attached to the email announcement: ​
  • Data Summary – the form used to summarize ombudsman quality measures and other data reviewed for the DSR
  • AGI Review Excel – contains criteria for reviewing each category of AGI entries, and select entries for the Regional Program and State Office to review in preparation of the monitoring visit 
  • Prep Meeting Template – the form used by the State Office to summarize results of the program review
  • Designation Letter and Draft APQ – these are templates used to report the results of the review, notify the Regional Program of continued designation, and the APQ outlines the specific actions the program will take to improve areas discussed during the monitoring visit

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Ombudsman Program Outcome Measures
The Ombudsman Outcomes Project was designed to identify additional outcome measures that could be used to describe the impact of the ombudsman program's work on the lives of long-term care residents and the long-term care system as a whole. This report describes the results of that effort. The data and other state information on which this report is based was collected over three years, ending with a final conference call with ombudsman staff from the four grantee states, held in January 2004. The final report incorporates feedback subsequently provided by the ombudsmen who participated in the project. This report was produced by the National Association of State Units on Aging and was conducted under the National Long Term Care Ombudsman Resource Center.

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